Laparoscopic treatment of genitourinary prolapse: double sacral fixation

This video demonstrates the use of two pieces of mesh to suspend the levator ani and the cervix and bladder from the sacral promontory. This is a complex operation and requires a detailed knowledge of anatomy demonstrated in this video as well as high level of laparoscopic skill.

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Laparoscopic treatment of genitourinary prolapse: double sacral fixation

Authors

Abstract

This video demonstrates the use of two pieces of mesh to suspend the levator ani and the cervix and bladder from the sacral promontory. This is a complex operation and requires a detailed knowledge of anatomy demonstrated in this video as well as high level of laparoscopic skill.

Classification

complex cases

Keywords

laparoscopic treatment,genitourinary prolapse,double sacral fixation,urology

Media type

Surgical video

Duration

25'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1556e.htm

Laparoscopic treatment of genitourinary prolapse: double sacral fixation

1. Patient and trocar placement 00'08''

This video will demonstrate laparoscopic treatment of genitourinary prolapse. The case is that of a 67-year-old female patient who presented at a urological consultation. The patient had dysuria as well as symptoms suggestive of a mechanical nature including incomplete voiding. She did not have any incontinence. Clinical examination revealed a grade 2 to 3 cystocele and a small rectocele which was not causing any symptoms. Examination also listed that the uterus was normal in size and position. The patient is placed in a supine position on the operating table with her buttocks on the edge of the table. The legs are supported by mobile stirrups and the hips are abducted. A urinary catheter is placed to drain the bladder. The assistant will be positioned between the patient’s legs and will use a ribbon-shaped vaginal retractor in order to help the vaginal dissection. The vaginal retractor is essential for the dissection of the posterior aspect of the vagina which is otherwise very risky. The positioning of the patient is important in order to create enough space for the assistant. The anesthetist should be informed that the patient should be prevented from slipping when placed in the Trendelenburg position as this would hinder the use of the vaginal retractor. Now to the close-up view of the prolapse. The cystocele bulging anteriorly is clearly visible here. Now to the set-up. The patient is now in a Trendelenburg position. The Veress needle has been used to insufflate the abdominal cavity. The expansion of the abdomen at this stage is a guide to how much working space there will be for the procedure. Precaution helps to assess the extent of gaseous filling. Once the insufflation is complete, a 10mm optical trocar is introduced at the inferior margin of the umbilicus. This is the only 10mm trocar which will be used. A trocar is then placed in each iliac fossa to complete the conventional laparoscopic triangle. The camera is introduced and the inside of the abdominal wall is visualized via the insertion of the instrumental ports. This facilitates the avoidance of any blood vessels during insertion. The surgeon follows the trocar with the camera in order to prevent any trauma during insertion. A further trocar is placed in the midline and this will be used by the surgeon’s right hand. The trocar in the left iliac fossa is for the surgeon’s left hand. Again, the assistant carefully observes the trocar insertion with the camera. It is important to avoid any stripping of the peritoneum during this initial step of the procedure. Here are the epigastric vessels visible from the inside. These vessels should certainly be avoided. The surgeon should be in a comfortable position with the elbows flexed at 90 degrees and the wrists in full extension so that he/she can perform surgical maneuvers with these.

2. Exploration and exposure 03'07''

Now to the laparoscopic view. The small bowel loops are gently positioned away from the pelvis in order to create a good operative field. Here is an adhesion on the sigmoid colon which needs to be divided to free the sigmoid loop. The adhesion is divided from the medial side. The dissection is then continued on the lateral side to free the sigmoid loop. This space is essential for the procedure. Once a correct exposure is achieved, the sacral promontory should come into view. The anatomy is now clear with the small bowel which has now been placed cephalad visible here. This is the sacral promontory. The Trendelenburg position which helps the exposure should not be too steep for this procedure. The promontory is an important landmark. The white fibres of the ligamental structures round the lumbosacral junction are situated here. Here’s the right common iliac artery and the ureter. The position of the ureter must be kept in mind at all times in order to prevent any contact with the prostatic material which will be inserted as this may damage the ureter. The next step of the procedure is to suspend the uterus onto the anterior abdominal wall in order to improve the surgical access to the rectouterine pouch. This is performed by the insertion of a straight percutaneous needle just above the pubic symphysis. This needle is grasped by the surgeon who takes a bite of the superior anterior aspect of the uterus. The needle is then pushed through outwards to complete the suspension. Here we see the pouch of Douglas which is very deep and wide. The dissection will be started here. The uterosacral ligament seen here is an important landmark as it defines the lateral limit of the cervix as well as the superior limit of the posterior prosthesis fixation.

3. Rectovaginal dissection 05'34''

The assistant introduces the ribbon-shaped retractor now per vaginally in order to facilitate the dissection. Once the retractor is pulled upwards, the posterior aspect of the vagina becomes clearly visible. The peritoneum is grasped in the midline and incised. The correct plane of dissection is in the fatty tissue just deep to this position. The peritoneum is further opened and the gaseous pressure in the abdomen facilitates the dissection. The dissection is continued in this plane between the posterior vaginal wall and the rectum. The retractor is repositioned to further facilitate the dissection by clarifying the correct dissection planes. There are several ways of performing this procedure and some surgeons prefer to start with the dissection at the level of the sacral promontory. However, dissecting the rectouterine pouch first enables the early detection of the levator ani muscles for the posterior attachments of the prosthesis. The dissection is continued laterally in order to create enough exposure and for the clear identification of the landmarks. Dissection must be performed adjacent to the vaginal wall in order to prevent any injury to it. The dissection is continued deeper and laterally into the pararectal space towards the levator ani muscles. The fatty tissue of the pararectal space is visible now. The border of the rectum becomes more visible as the dissection is continued deeper while retracting the rectum medially. Careful dissection should be performed in this area in order to avoid injury to the rectal wall. The risk of neurovascular injury is relatively low in this type of dissection. The muscular plane of the levator ani has now been reached. The vascular pedicles must be respected during this step in order to avoid any devascularization of the rectal wall. Here’s the middle rectal pedicle just posterior to the dissection plane which must be respected. The lateral wall of the vagina, lower rectum and the surface of the levator ani are now visible. The dissection is now continued to create space for the prostatic material. Enough space must be created to position the posterior prostatic mesh away from the rectal wall in order to avoid any injury. This may lead to functional problems of the rectum. Now the dissection is performed on the opposite side. The vaginal retractor again facilitates the dissection. The same landmarks are used and the vascular pedicles are avoided. Again the correct dissection plane is identified for bloodless dissection. The levator ani is again visible on the left side. The perimysium of the levator is ideal tissue for the fixation of the prosthesis. Enough space is created for the insertion of the needle and its rotation during fixation of the mesh. We now move on to dissection at the midline. The plane between the vagina and rectum is opened. This overview demonstrates the dissection which has been performed. The dissection is continued until the rectovaginal fibres come into view which indicate the inferior limit of the dissection.

4. Posterior prosthesis fixation 10'14''

This completes the rectouterine dissection. Now to the insertion of the prostatic mesh. A Parietex® prosthesis is used. This mesh is covered with collagen allowing good biological compatibility. This is the posterior leaf of the prosthesis which is pre-cut and one-shaped. The suture is prefixed onto the mesh to facilitate intraperitoneal handling. The 10mm port is used to introduce the prosthesis using a needle holder. Once inside, the needle is grasped and a bite is taken on the levator for the fixation of the mesh. The ideal position for placement of the mesh is lateral and anterior I order to avoid contact of the mesh with the rectum. A good bite of the muscle is taken. The mesh is then snugged down onto the dissected area. Configuration of the posterior mesh can now be appreciated. The suture is then tied to secure the mesh. The mesh is then fixed on the opposite side in the same manner. The knot is slipped down using the same principles of deep knot-tying which are used in open surgery. The deepest and most technically demanding part of the procedure is now complete. A further suture is placed in the midline to close the space between the posterior vaginal wall and the mesh. Care is taken not to take too big a bite at this point. Again it is emphasized that any contact between the mesh and the rectum should be avoided at all cost. We can see the pouch of Douglas here and the uterosacral ligament on the left side. The suture is placed through the uterosacral ligament and the paravaginal tissues as part of the posterior fixation. This stitch provides a lot of the mechanical strength needed for the reduction of the prolapse. The stitch is taken from the posterior leaf of peritoneum in order to close the gap in the rectovaginal space. The peritoneum needs to be placed over the mesh for the incorporation of the mesh into the peritoneal tissue. The same is performed on the right side. This completes the preparation of the distal portion of the posterior mesh and this is secured. A second throw is placed while the assistant controls the first throw.

5. Promontory exposure 13'08''

We now move to the sacral promontory. The sigmoid colon is retracted laterally in order to create the right exposure. The peritoneum over the promontory is picked up and incised using monopolar scissors. The dissection is continued until the fibre structures around the promontory are reached. Here is the presacral vein which should not be dissected and can be controlled with the stitch which will secure the mesh. The dissection is continued and the pearly white color of the ligamental structures which are the target of our proximal stitch come into view. Space is created to anchor the mesh. The peritoneum is further divided in this theoretically avascular plane. The incision is extended to the right side where the anterior leaf of the mesh which will be inserted later will be placed. The knot which has been previously tied is cut and the dissection is continued deep on the medial aspect of the uterosacral ligament. Here we come to the area of the ureter which runs lateral to the uterosacral ligament. Ureteric injury is rare during this step. It must be kept in mind. The peritoneum is progressively detached. Once the space has been created, a stitch is placed through the posterior leaf of the peritoneum. Then the lateral edge of the mesh and the now bare uterosacral ligament in order to fix the prosthesis.

6. Vesicovaginal dissection 15'55''

The next step is to perform a dissection in order to accommodate a second prostatic mesh which will be fixed anterior to the uterus in the vesicovaginal space. The peritoneum is incised over the posterior uterus in the area of the right broad ligament. The suspension of the uterus again facilitates the exposure. The dissection is continued anteriorly and inferiorly towards the vagina and the bladder. A window is created between the rectouterine and the vesicovaginal spaces. The peritoneum is opened over the vesicovaginal space. The peritoneum is progressively detached on both anterior and posterior aspect with the help of the vaginal retractor. The dissection is continued inferiorly and the fibres between the vagina and the bladder are progressively divided. The limit of this dissection should not be too caudal as this risks damage to the trigone of the bladder and ureters. We can see here the balloon of the urinary catheter which is being moved by the assistant and is at the level of the uterine cervix. This is a good place to stop the dissection. Contact between the prosthesis and the trigone of the bladder should be avoided as is the case with the rectum.

7. Anterior prosthesis fixation 18'11''

We now move on to the dissection of the anterior prostatic mesh. The vagina is retracted downwards and a stitch is placed in the anterior vaginal wall fibres posterior to the bladder neck. It is important not to breach the vaginal and bladder walls as vesicovaginal fistulas may occur. Once the stitch is placed, the mesh is parachuted down with a to and fro movement while pulling on the prefixed thread. A knot is tied to secure the inferior corner of the mesh. The stitch is then taken in a continuous manner to fix the lateral edge of the anterior mesh onto the lateral aspect of the uterine cervix in order to avoid the uterine prolapse. The uterine prolapse despite the successful treatment of cystocele has been a problem previously with this technique when only a subcervical fixation was performed. A knot is tied again. The same fixation is performed on the opposite side. One this is done, the anterior fixation of the mesh is complete. The anterior prostatic mesh is brought through the window which has been created under the right uterine tube.

8. Promontofixation 20'05''

The 2 pieces of mesh are then placed over one another in the area of the sacral promontory, thus completing the trouser configuration of the prosthesis. A needle is inserted through the optical trocar. A stitch is then placed in the already dissected area of the sacral promontory, then through each limb of the prosthesis. Slight tension on the mesh as shown here is ideal for the mechanical benefit from this procedure. The whole complex is secured by knots. This completes placement of the prosthesis. Any excess mesh material is removed. We can see the configuration of the prosthesis clearly here supporting both the anterior and posterior components of the prolapse.

9. Repair of peritoneum 21'34''

The last step of the procedure is to close the peritoneum over the prosthesis allowing the integration of the prostatic material into the peritoneum. This is done using a double Vicryl stitch. The anterior vesicovaginal opening is first closed in a continuous manner. The suture is then brought through the peritoneal window in the broad ligament in a manner following the prosthesis. The running stitch continues behind the uterus in order to close the rectouterine defect on the right side. This leaf of peritoneum is joined with the opposite side in a longitudinal manner. We remind ourselves that the right ureter at this level is situated laterally and therefore there is no danger of damaging this during this step. The peritoneum is now closed. A final look at the pararectal space to check for hemostasis is performed. No drains have been used in this procedure. And now to the external view. As visible here, the prolapse has been successfully reduced. This is the end of the operation.